What is the difference between conduct disorder and ASPD?

Antisocial personality disorder (ASPD) — a psychological condition characterized by a lack of empathy and a remorseless disregard for and violation of the rights of others — is only diagnosed in people 18 and over.

Symptoms of ASPD begin in childhood or adolescence, but when children show serious signs of antisocial behavior, they are diagnosed instead with conduct disorder. While not all children with conduct disorder end up developing antisocial personality disorder, “all adults with ASPD first show signs of psychopathy during childhood,” explains Kalina J. Michalska, PhD, an assistant professor of psychiatry at the University of California in Riverside who studies children with this issue.

That said, conduct disorder (CD) is hard to quantify, with difficult-to-identify causes. (1) “The disorder arises from the poorly understood interaction of neurobiological, genetic, environmental, and social-developmental factors, as well as adverse childhood experiences, which may negatively influence a growing child’s capacity for empathy and moral development,” says James B. McCarthy, PhD, an associate professor of psychology at Pace University in New York City.

In the United States, researchers estimate that conduct disorder affects about 2 to 10 percent of the population, with a higher rate for boys. (2,3While some children with conduct disorder go on to develop ASPD in adulthood — maybe in the range of 30 to 40 percent, says Dr. Michalska — most don’t.

What Are the Signs of Conduct Disorder?

The criteria experts use to determine if a child or adolescent has conduct disorder fall into the categories below. For a diagnosis to be made, says Michalska, a child should have exhibited several of these behaviors over the previous year, with at least one in the most recent six months. “When we see kids with more than three of these behaviors, that’s a really big red flag.”

  • Aggression Toward People and Animals This includes bullying, threatening or attempting to intimidate others, forcing sexual activity, initiating physical fights, and using weapons. Cruelty to animals, notes Michalska, doesn’t mean “normal” behavior like cutting an earthworm in half to see how it works. “This is really disturbing stuff like cutting off a kitten’s tail,” she says. 
  • Destruction of Property The child breaks or damages others’ property on purpose, or intentionally sets fires — not for fun (such as a bonfire), but to cause damage. 
  • Deceitfulness, Lying, and Stealing Breaking into a home, building, or car; lying to avoid trouble or obligations; shoplifting
  • Serious Rule Violations This includes actions such as staying out at night without permission or against parental wishes, running away repeatedly, and school truancy that goes beyond occasionally skipping classes.

In a recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), an additional “specifier” was added to bring more clarity to a diagnosis of CD. “It’s ‘conduct disorder with limited prosocial emotions,’” explains Michalska, defined as displaying a lack of remorse or guilt; callousness and lack of concern; and shallow emotions.

“When you have limited prosocial emotion, you might see a child starting a fight or hurting an animal, and not caring about the effects of their actions, not feeling remorse.” That helps separate the children with more serious or intractable CD from those who, say, exhibit bad behavior because they can’t control themselves, but then get very upset about it afterward, Michalska explains.

How Is Conduct Disorder in Children Treated?

The most important factor in treating children with conduct disorders is whole-family involvement, says Dr. McCarthy. “If parents and other important adult figures are emotionally present, caring, responsible, and appropriately authoritative, and if they serve as role models to demonstrate sensitivity, compassion, and moral behavior,” positive outcomes in treatment are possible.

What is the difference between conduct disorder and ASPD?

But it’s not simple, in part because many children with this and related disorders often live in the kind of family environment that works against or worsens their problems, he adds. 

Here’s a look at treatment approaches for CD:

  • What Doesn’t Work: Punishment Children with conduct disorder tend to be punishment-insensitive; it just isn’t effective because they may lack the ability to feel remorse, says Michalska.
  • What Can Work: Multisystemic Therapy This is an intensive treatment that requires the cooperation of the entire family. It generally involves therapists working closely with the child and family to change problematic aspects of the child’s environment, such as chaos and disorganization. “We may look at certain aspects of the environment and try to substitute things that are more appropriate," says Michalska. A number of studies have shown that it can be effective. (4)
  • What May Work: Medication“Sometimes stimulant drugs, like those used to treat ADHD, look as though they’re effective,” says Michalska, but that may be because ADHD is often comorbid with CD. About 16 to 20 percent of children with conduct disorder also have ADHD. (2)

When to Worry About Conduct Disorder

As serious and scary as the signs and symptoms of CD clearly are, it’s important to remember that many children simply grow out of these kinds of behaviors. But there’s still a cause for concern, says Michalska, particularly if the most serious symptoms arise in children prior to age 7 or 8, because that may indicate intractability. “If you see CD traits in early childhood, that usually leads to more chronic, more persistent, long-term problems,” she says.

If parents or other adults see reason for concern about children engaging in these behaviors and displaying a lack of empathy or remorse, “consulting with a qualified, well-trained mental health professional with experience working with at-risk youth is the first and most important step,” says McCarthy.

1. Kessler RC, Nelson CB, McGonagle KA, Edlund MJ, Frank RG, Leaf PJ. The epidemiology of co-occurring addictive and mental disorders: Implications for prevention and service utilization. Am J Orthopsychiatry. 1996;66:17–31. [PubMed] [Google Scholar]

2. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study. JAMA. 1990;264:2511–2518. [PubMed] [Google Scholar]

3. Alterman AI, Tarter RE. An examination of selected typologies: hyperactivity, familial, and antisocial alcoholism. In: Galanter M, editor. Recent Developments in Alcoholism, Volume 4. New York, NY: Plenum; 1986. pp. 169–189. [PubMed] [Google Scholar]

4. Cadoret R, Troughton E, Widmer R. Clinical differences between antisocial and primary alcoholics. Compr Psychiatry. 1984;25:1–8. [PubMed] [Google Scholar]

5. Epstein EE, Ginsburg BE, Hesselbrock VM, Schwarz JC. Alcohol and drug abusers subtyped by antisocial personality and primary or secondary depressive disorder. In: Babor TF, Hesselbrock V, Meyer RE, Shoemaker W, editors. Types of Alcoholics: Evidence from Clinical, Experimental, and Genetic Research. New York, NY: New York Academy of Sciences; 1994. pp. 187–201. [PubMed] [Google Scholar]

6. Hesselbrock MN. Childhood behavior problems and adult antisocial personality disorder in alcoholism. In: Meyer RE, editor. Psychopathology and Addictive Disorders. New York, NY: Guilford Press; 1986. pp. 78–94. [Google Scholar]

7. Hesselbrock MN, Hesselbrock VM, Babor TF, Stabenau JR, Meyer RE, Weidenman M. Antisocial behavior, psychopathology and problem drinking in the natural history of alcoholism. In: Goodwin DW, Teilman-Van Dusen K, Mednick SA, editors. Longitudinal Research in Alcoholism. Boston, Mass: Kluwer-Nijhoff Publishing; 1984. pp. 197–213. [Google Scholar]

8. Cloninger CR. Neurogenetic adaptive mechanisms in alcoholism. Science. 1987;236:410–416. [PubMed] [Google Scholar]

9. Babor TF, Hofmann M, DelBoca K, et al. Types of alcoholics, I: evidence for an empirically derived typology based on indicators of vulnerability and severity. Arch Gen Psychiatry. 1992;49:599–608. [PubMed] [Google Scholar]

10. Jellinek EM. Alcoholism: a genus and some of it species. Can Med Assoc J. 1960;83:1341–1345. [PMC free article] [PubMed] [Google Scholar]

11. Neumann CS, Grimes K, Walker E, Baum K. Developmental pathways to schizophrenia: behavioral subtypes. J Abnorm Psychol. 1995;104:558–566. [PubMed] [Google Scholar]

12. Robins LN. Deviant Children Grown Up. Huntington, NY: Robert E. Krieger Publishing Company; 1966. [Google Scholar]

13. Robins LN, Price RK. Adult disorders predicted by childhood conduct problems: results from the NIMH Epidemiologic Catchment Area project. Psychiatry. 1991;54:116–132. [PubMed] [Google Scholar]

14. Watt NF. Patterns of childhood social development in adult schizophrenics. Arch Gen Psychiatry. 1978;35:160–165. [PubMed] [Google Scholar]

15. Bland RC, Newman SC, Orn H. Schizophrenia: lifetime comorbidity in a community sample. Acta Psychiatr Scand. 1987;75:383–391. [PubMed] [Google Scholar]

16. Hodgins S, Toupin J, Côté G. Schizophrenia and antisocial personality disorder: a criminal combination. In: Schlesinger LB, editor. Explorations in Criminal Psychopathology: Clinical Syndromes with Forensic Implications. Springfield: Ill Charles C Thomas; 1996. pp. 217–237. [Google Scholar]

17. Jackson HJ, Whiteside HL, Bates GW, Rudd RP, Edwards J. Diagnosing personality disorders in psychiatric inpatients. Acta Psychiatr Scand. 1991;83:206–213. [PubMed] [Google Scholar]

18. Fowler IL, Carr VJ, Carter NT, Lewin TJ. Patterns of current and lifetime substance use in schizophrenia. Schizophr Bull. 1998;24:443–455. [PubMed] [Google Scholar]

19. Weaver T, Madden P, Charles V, et al. Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. Br J Psychiatry. 2003;183:304–313. [PubMed] [Google Scholar]

20. Mueser K, Drake R, Wallach M. Dual diagnosis: a review of etiological theories. Addict Behav. 1998;23:717–734. [PubMed] [Google Scholar]

21. Caton CL, Shrout PE, Eagle PF, Opler LA, Felix AF, Dominguez B. Risk factors for homelessness among schizophrenic men: a case-control study. Am J Public Health. 1994;84:265–270. [PMC free article] [PubMed] [Google Scholar]

22. Caton CLM, Shrout PE, Dominguez B, Eagle PF, Opler LA, Cournos F. Risk factors for homelessness among women with schizophrenia. Am J Public Health. 1995;85:1153–1156. [PMC free article] [PubMed] [Google Scholar]

23. Hodgins S, Hiscoke UL, Freese R. The antecedents of aggressive behavior among men with schizophrenia: a prospective investigation of patients in community treatment. Behav Sci Law. 2002;21:523–546. [PubMed] [Google Scholar]

24. Moran P, Hodgins S. The correlates of comorbid antisocial personality disorder in schizophrenia. Schizophr Bull. 2004;30:791–802. [PubMed] [Google Scholar]

25. Mueser KT, Rosenberg SD, Drake RE, et al. Conduct disorder, antisocial personality disorder, and substance use disorders in schizophrenia and major affective disorders. J Stud Alcohol. 1999;60:278–284. [PubMed] [Google Scholar]

26. Mueser KT. Clinical interventions for severe mental illness and co-occurring substance use disorder. Acta Neuropsychiatr. 2004;16:26–35. [PubMed] [Google Scholar]

27. Mueser KT, Drake RE, Ackerson TH, Alterman AI, Miles KM, Noordsy DL. Antisocial personality disorder, conduct disorder, and substance abuse in schizophrenia. J Abnorm Psychol. 1997;106:473–477. [PubMed] [Google Scholar]

28. Douglas KS, Webster CD, Hart SD, Eaves D, Ogloff JRP. The HCR-20 Violence Risk Management Companion Guide. Vancouver: Mental Health, Law, and Policy Institute, Simon Fraser University; 2001. [Google Scholar]

29. Webster CD, Douglas KS, Eaves D, Hart SD. HCR-20: Assessing Risk for Violence Version 2. Vancouver: Mental Health Law and Policy Institute, Simon Fraser University; 1997. [Google Scholar]

30. Crocker AG, Mueser KT, Clark RE, McHugo GJ, Ackerson T, Alterman AI. Antisocial personality, psychopathy and violence in persons with dual disorders: a longitudinal analysis. Crim Justice Behav. 2005;32:452–476. [Google Scholar]

31. Essock SM, Mueser KT, Drake RE, et al. Assertive community treatment versus standard case management for patients receiving integrated treatment for co-occurring severe mental illness and substance use disorder. Psychiatr Serv. 2006;57:185–196. [PubMed] [Google Scholar]

32. Spitzer R, Williams J, Gibbon M, First M. Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). New York, NY: Biometrics Research Department, New York State Psychiatric Institute; 1988. [Google Scholar]

33. First MB, Spitzer RL, Gibbon M, Williams JBW, Benjamin L. Structured Clinical Interview for DSM-IV Axis-II Personality Disorders (SCID-II) (Version 2.0). New York, NY: Biometrics Research Department, New York State Psychiatric Institute; 1994. [Google Scholar]

34. Tessler R, Goldman H. The Chronically Mentally Ill: Assessing Community Support Programs. Cambridge, Mass: Ballinger Press; 1982. [Google Scholar]

35. Lukoff D, Nuechterlein KH, Ventura J. Manual for the Expanded Brief Psychiatric Rating Scale (BPRS) Schizophr Bull. 1986;12:594–602. [Google Scholar]

36. Endicott J, Spitzer RL, Fleiss JL, Cohen J. The Global Assessment Scale: a procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry. 1976;33:766–771. [PubMed] [Google Scholar]

37. Sobell LC, Sobell MB. Timeline Follow-Back: a technique for assessing self-reported alcohol consumption. In: Litten RZ, Allen J, editors. Measuring Alcohol Consumption: Psychosocial and Biological Methods. Totowa, NJ: Humana Press; 1992. pp. 41–72. [Google Scholar]

38. McLellan AT, Kushner H, Metzger D, et al. The fifth edition of the Addiction Severity Index: historical critique and normative data. J Subst Abuse Treatment. 1992;9:199–213. [PubMed] [Google Scholar]

39. Drake RE, Osher FC, Noordsy DL, Hurlbut SC, Teague GB, Beaudett MS. Diagnosis of alcohol use disorders in schizophrenia. Schizophr Bull. 1990;16:57–67. [PubMed] [Google Scholar]

40. Mueser KT, Drake RE, Clark RE, McHugo GJ, Mercer-McFadden C, Ackerson T. Toolkit for Evaluating Substance Abuse in Persons with Severe Mental Illness. Cambridge, Mass: Evaluation Center at HSRI; 1995. [Google Scholar]

41. McHugo GJ, Drake RE, Burton HL, Ackerson TH. A scale for assessing the stage of substance abuse treatment in persons with severe mental illness. J Nerv Ment Dis. 1995;183:762–767. [PubMed] [Google Scholar]

42. Drake RE, Mueser KT, McHugo GJ. Clinician Rating Scales: Alcohol Use Scale (AUS), Drug Use Scale (DUS), and Substance Abuse Treatment Scale (SATS) In: Sederer LI, Dickey B, editors. Outcomes Assessment in Clinical Practice. Baltimore, Md: Williams and Wilkins; 1996. pp. 113–116. [Google Scholar]

43. Chawarski MC, Pakes J, Schottenfeld R. Assessment of HIV risk. J Addict Dis. 1998;17(4):49–59. [PubMed] [Google Scholar]

44. Cadoret RJ, O'Forman TW, Troughton E, Heywood E. Alcoholism and antisocial personality: interrelationships, genetic and environmental factors. Arch Gen Psychiatry. 1985;42:161–167. [PubMed] [Google Scholar]

45. Schuckit M. Alcoholism and sociopathy: diagnostic confusion. Q J Stud Alcohol. 1973;34:157–164. [PubMed] [Google Scholar]

46. Vaillant G. Natural history of male alcoholism, V: is alcoholism the cart or the horse to sociopathy? Br J Addict. 1983;78:317–326. [PubMed] [Google Scholar]

47. Cottler LB, Price RK, Compton WM, Mager DE. Subtypes of adult antisocial behavior among drug abusers. J Nerv Ment Dis. 1995;183:154–161. [PubMed] [Google Scholar]

48. Desai RA, Lam J, Rosenheck RA. Childhood risk factors for criminal justice involvement in a sample of homeless people with serious mental illness. J Nerv Ment Dis. 2000;188:324–332. [PubMed] [Google Scholar]

49. Burt MR. Over the Edge: The Growth of Homelessness in the 1980s. New York, NY: Russell Sage Foundation and Urban Institute Press; 1992. [Google Scholar]

50. Martell DA, Rosner R, Harmon RB. Base-rate estimates of criminal behavior by homeless mentally ill persons in New York City. Psychiatr Serv. 1995;46:596–601. [PubMed] [Google Scholar]

51. Teplin LA, Pruett NS. Police as streetcorner psychiatrist: managing the mentally ill. Int J Law Psychiatry. 1992;15:139–156. [PubMed] [Google Scholar]

52. Robins LN, Tipp J, Przybeck TR. Antisocial personality disorder. In: Robins LN, Regier DA, editors. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. New York, NY: Free Press; 1991. pp. 258–290. [Google Scholar]

53. Rutter M, Giller H, Hagell A. Antisocial Behavior by Young People. Cambridge, UK: Cambridge University Press; 1998. [Google Scholar]

54. Whitters A, Cadoret RJ, McCalley-Whitters MK. Further evidence for heterogeneity in antisocial alcoholics. Compr Psychiatry. 1987;28:513–519. [PubMed] [Google Scholar]

55. Carey MP, Carey KB, Maisto SA, Gordon CM, Vanable PA. Prevalence and correlates of sexual activity and HIV-related risk behavior among psychiatric outpatients. J Consult Clin Psychol. 2001;69:846–850. [PMC free article] [PubMed] [Google Scholar]

56. Cournos F, Guido JR, Coomaraswamy S, Meyer-Behlburg H, Sugden R, Horwath E. Sexual activity and risk of HIV infection among patients with schizophrenia. Am J Psychiatry. 1994;151:228–232. [PubMed] [Google Scholar]

57. Kalichman S, Kelly J, Johnson J, Bulto M. Factors associated with risk for HIV infection among chronic mentally ill adults. Am J Psychiatry. 1994;151:221–227. [PubMed] [Google Scholar]

58. Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model of temperament and character. Arch Gen Psychiatry. 1993;50:975–990. [PubMed] [Google Scholar]

59. Schalling D. Psychopathy-related personality variables and the psychophysiology of socialization. In: Hare RD, Schalling D, editors. Psychopathic Behavior: Approaches to Research. New York, NY: John Wiley and Sons; 1978. [Google Scholar]

60. Schalling D, Edman G, Åsberg M. Impulsive cognitive style and inability to tolerate boredom: psychobiological studies of temperamental vulnerability. In: Zuckerman M, editor. Biological Bases of Sensation Seeking, Impulsivity, and Anxiety. Hillsdale, NJ: Lawrence Erlbaum; 1983. pp. 123–145. [Google Scholar]

61. Hodgins S, Tiihonen J, Ross D. The consequences of conduct disorder for males who develop schizophrenia: associations with criminality, aggressive behavior, substance use, and psychiatric services. Schizophr Res. 2005;78:323–335. [PubMed] [Google Scholar]

62. Tengström A, Hodgins S, Grann M, Långström N, Kullgren G. Schizophrenia and criminal offending: the role of psychopathy and substance misuse. Crim Justice Behav. 2004;31:1–25. [Google Scholar]

63. Brooner RK, Schmidt CW, Felch LJ, Bigelow GE. Antisocial behavior of intravenous drug abusers: implications for diagnosis of antisocial personality disorder. Am J Psychiatry. 1992;149:482–487. [PubMed] [Google Scholar]

64. Abram KM. The effect of co-occurring disorders on criminal careers: interaction of antisocial personality, alcoholism, and drug disorders. Int J Law Psychiatry. 1989;12:133–148. [PubMed] [Google Scholar]

65. Tengström A, Hodgins S, Kullgren G. Men with schizophrenia who behave violently: the usefulness of an early versus late starters typology. Schizophr Bull. 2001;27:205–218. [PubMed] [Google Scholar]

66. Fulwiler C, Grossman H, Forbes C, Ruthazer R. Early-onset substance abuse and community violence by outpatients with chronic mental illness. Psychiatr Serv. 1997;48:1181–1185. [PubMed] [Google Scholar]

67. Fulwiler C, Ruthazer R. Premorbid risk factors for violence in adult mental illness. Compr Psychiatry. 1999;40:96–100. [PubMed] [Google Scholar]

68. Lamberti JS, Weisman R, Faden DI. Forensic assertive community treatment: preventing incarceration of adults with severe mental illness. Psychiatr Serv. 2004;55:1285–1293. [PubMed] [Google Scholar]

69. Rotter M, McQuisition HL, Broner N, Steinbacher M. The impact of the “incarceration culture” on reentry for adults with mental illness: a training and group treatment model. Psychiatr Serv. 2005;56:265–267. [PubMed] [Google Scholar]

70. Broner N, Lattimore PK, Cowell AJ, Schlenger WF. Effects of diversion on adults with co-occurring mental illness and substance use: outcomes from a national multi-site study. Behav Sci Law. 2004;22:519–541. [PubMed] [Google Scholar]

71. Broner N, Mayrl DW, Landsberg G. Outcomes of mandated and nonmandated New York City jail diversion for offenders with alcohol, drug, and mental disorders. Prison J. 2005;85:18–49. [Google Scholar]

72. Frisman LK, Lin H-J, Sturges GE, Levinsom M, Baranoski MV, Pollard NM. Outcomes of court-based jail diversion programs for people with co-occurring disorders. J Dual Diagn. In press. [Google Scholar]

73. Mueser KT, Noordsy DL, Drake RE, Fox L. Integrated Treatment for Dual Disorders: A Guide to Effective Practice. New York, NY: Guilford Press; 2003. [Google Scholar]

74. Peters RH, Hills HA. Community treatment and supervision strategies for offenders with co-occurring disorders: what works? In: Latessa E, editor. Strategic Solutions: The International Community Corrections Association Examines Substance Abuse. Lanham: Md: American Correctional Association; 1999. pp. 81–137. [Google Scholar]

75. Landenberger NA, Lipsey MW. The positive effects of cognitive-behavioral programs for offenders: a meta-analysis of factors associated with effective treatment. J Exp Crim. In press. [Google Scholar]

76. Lipsey MW, Chapman G, Landenberger NA. Cognitive-behavioral programs for offenders. Ann Am Acad Pol Soc Sci. 2001;578:144–157. [Google Scholar]

77. Berkson J. Limitations of the application of four-fold tables to hospital data. Biol Bull. 1949;2:47–53. [PubMed] [Google Scholar]

Page 2

Demographic and Background Characteristics: Categorical Variables

Categorical VariablesNo CD/ASPD (N = 92) n (%)CD Only (N = 15) n (%)Adult ASPD Only (N = 33) n (%)Full ASPD (N = 38) n (%)χ2 Test
    Male60 (65.2)11 (73.3)20 (60.6)34 (89.5)9.37*
    Female32 (34.8)4 (26.7)13 (39.4)4 (10.5)
    White24 (26.1)5 (33.3)9 (27.3)10 (26.3)0.35
    Nonwhite68 (73.9)10 (66.7)24 (72.7)28 (73.7)
Marital Status
    Ever married27 (29.3)3 (20.0)12 (36.4)6 (15.8)4.52
    Never married65 (70.7)12 (80.0)21 (63.6)32 (84.2)
    High school graduate50 (54.3)2 (13.3)20 (60.6)16 (42.1)11.17**
    Less than high school42 (45.7)13 (86.7)13 (39.4)22 (57.9)
    Living with family43 (46.7)5 (33.3)10 (30.3)12 (31.6)4.27
    Recently homeless32 (34.8)3 (20.0)20 (60.6)16 (42.1)10.35**
    Recently worked34 (37.0)4 (26.7)7 (21.2)12 (31.6)3.00
    Currently working12 (13.0)3 (20.0)1 (3.0)3 (7.9)4.73
    Chronic medical problems33 (35.9)8 (53.3)12 (36.4)16 (42.1)1.92
    Prescribed medications for physical problem21 (22.8)3 (20.0)8 (24.2)6 (15.8)0.95